Radical resection of a giant recurrent chondrosarcoma of the anterior chest wall

A 63-year-old woman presented with a giant anterior chest wall tumor. She had undergone an operation 5 years previously for sternal chondrosarcoma at another medical center. Here, the patient underwent further surgery: a radical en bloc resection of an 18 × 18 cm portion of her anterior chest wall was performed, including the proximal ends of both clavicles, the first three costochondral joints bilaterally, and the tumor mass. The large chest wall defect was reconstructed in two layers: the first with a polypropylene mesh and a pedicled latissimus dorsi muscle flap as the second. She is healthy 20 months postoperatively.     

Reconstruction of large anterior full-thickness defect in the chest wall after resection of chondrosarcoma

Radical removal of a chondrosarcoma resulted in a very large full-thickness defect of the anterior chest wall, including the body of the sternum and adjacent parts of the ribs on both sides. The defect was closed with a double layer of Marlex mesh supported by metal bars bridging the gaps between the ends of resected ribs. This prosthesis was covered with bilateral latissimus dorsi muscle flaps and a split-thickness skin graft. The result, from both the functional and the cosmetic points of view, was excellent. The method permits closure of very large chest wall defects, enabling extensive radical removal of malignant tumours to prevent local recurrence.     

Scoliosis after chest wall resection

Background data

There has been an increased focus on the role of rib abnormalities in the development of scoliosis. Rib resection may influence the development of scoliosis. Although scoliosis has been identified in patients after thoracotomy, most of the currently available information is from case reports.

Methods

We examined records of 37 patients who underwent a chest wall or rib resection for rib lesions at our institution during the period of 1992 to 2005. Adequate data was available in 21 patients. We gathered data on demographic information, location of resection, and changes in curvature after resection based on radiograph or scout CT films at the latest follow-up appointment.

Results

Fourteen of 21 patients developed scoliosis with a mean Cobb angle of 25.8° (10°–70°). Eleven of these 14 patients had a progressive spinal deformity after chest wall resection with an average change in curvature of 29° (10°–70°). Eight of those 11 developed a convex toward the resection, while 3/11 developed a convex away from the resection. Seven of the eight patients with resections that included a rib superior to the sixth rib developed scoliosis, while four of 13 with resections below the sixth rib developed scoliosis.

Conclusion

Patients who have had a rib or chest wall resection are at risk for developing scoliosis, particularly if the resection is performed above the sixth rib.     

Factors affecting long-term survival after en-bloc resection of lung cancer invading the chest wall.

OBJECTIVE: Several reports emphasize the importance of en-bloc resection as the optimal surgical treatment of lung cancer with chest wall invasion. We investigated possible factors which could affect long-term survival following radical resection of these tumors. METHODS: Between 1981 and 1998, 100 patients (90 male; ten female), with a median age of 60 years (36-84), underwent radical en-bloc resection of non-small cell lung cancer (NSCLC) with chest wall involvement. Patients with superior sulcus tumors invading the thoracic inlet were excluded from this series. There were 43 squamous and 57 non-squamous tumors. The median number of resected ribs was three (1-5). Lung resection included 73 lobectomies, two bilobectomies, 18 pneumonectomies and seven segmentectomies. Chest wall resection also extended to the sternum in one patient, the transverse process in one, the costotransverse foramen and hemivertebrae in two. All patients had a complete resection. Sixty-three patients received postoperative radiotherapy and 12 received chemotherapy. Histological data, including differentiation and depth of chest wall invasion, were carefully reviewed. The effect of various factors on survival were studied. RESULTS: There were four in-hospital deaths. Lymph node involvement was negative on surgical specimens in 65 patients, and 28 patients had positive N1 nodes; the final histology revealed seven N2 diseases. Chest wall invasion was limited to the parietal pleura in 29 patients and included intercostal muscles, bones and extrathoracic muscles in 67, 24 and seven cases, respectively. The overall 2-year survival rate was 41%. The 5-year survival for patients with N0, N1 and N2 disease was 22, 9 and 0%, respectively. A local recurrence occurred in 13 patients, with four having a new resection and 45 patients developing systemic metastases. The nodal status (N0-1 vs. N2; P=0. 026) and the number of resected ribs(<2 vs. >2; P=0.03) were survival predictors in univariate analysis. By multivariate analysis, the two independent factors affecting long-term survival were the histological differentiation (well vs. poorly differentiated; P=0. 01) and the depth of chest wall invasion (parietal pleura vs. others; P=0.024). CONCLUSIONS: Histological differentiation and depth of chest wall involvement were the main factors affecting long-term survival in this series. The role of induction chemotherapy for tumors with poor prognosis should be investigated.     

Long-term survival after multiple resections of a fibrosarcoma involving the lung and chest wall.

We report on the case of a 61-year-old male patient who developed a giant fibrosarcoma involving both the lung and chest wall. This patient underwent three extended resections including the chest wall in each case. Radiotherapy was administered after the last resection, when the tumor was obviously not completely removed. The patient lives a normal life with no signs of recurrence 5 years after his last resection. Multiple extended resections of large and aggressive sarcomas can result in long-term survival, with good quality of life, in adequately selected patients.     

Long-term survival after resection for bronchogenic carcinoma.

Of 915 resections for bronchogenic carcinoma over a 25-year period (1945-1969), 249 patients survived over 5 years; 127 of the patients eligible survived over 10 years, 61 over 15 years, and 22 over 20 years. The case material was divided into three time periods: 1945-49, 1950-59 and 1960-69, as well as by extent of resection. Lobectomy became the operation of choice, pneumonectomy being reserved for the more extensive lesions. Observed survival rates at 5, 10 and 15 years for 561 patients in the lobetomy series were 35, 22 and 15%, respectively, but strikingly increased to 41, 28 and 19% in the 1960-69 period. Observed rates for 354 patients having pneumonectomies were similar for three time periods, being 16, 8 and 6% at 5, 10 and 15 years, respectively. Relative survival rates for the lobectomy series at 5, 10 and 15 years rose from 33, 28 and 26%, repectively, in the 1950-59 period to 50, 39 and 35% in the last time period, becoming a near horizontal curve segment after 5 years. Dominant factors in survival were extent of the lesion and stage of nodal involvement, histologic type and location being less significant.     

Chest wall reconstruction after resection of primary malignant chest wall tumours

In order to review the development of chest wall reconstruction, 37 cases of primary malignant skeletal chest wall tumours treated since 1958 were studied. These included chondrosarcomas (20), Ewing's tumours (7) and solitary plasmacytomas (10). Skeletal reconstruction was performed in 24 patients. Before 1972, Marlex mesh alone was used. Since then, a sandwich of two layers of Marlex mesh with a filler of methyl methacrylate was utilised successfully producing better functional and cosmetic results. Primary soft tissue closure was possible in all but 5 cases in whom latissimus dorsi myocutaneous flaps were used. All but one patient had an uneventful postoperative recovery with none requiring postoperative ventilatory support. The overall survival of 46% at 5 years and 27% at 10 years was encouraging. Familiarity with the techniques of chest wall reconstruction enables wide excision of primary chest wall tumours and the palliation and treatment of other malignant, infective and degenerative conditions since even large defects can be reconstructed with little functional disturbance.     

Long-term survival of malignant fibrous histiocytoma of the chest wall by multidisciplinary treatment

We report a case of malignant fibrous histiocytoma (MFH) of the chest wall. A 70-year-old man admitted for recurrent chest wall tumor diagnosed for MFH histologically and resected 7 months and 13 months before admission. Chest computed tomography (CT) revealed a tumor located at right posterior chest wall. In May 1997, resection of the tumor was done (the 3rd operation), but metastasis to the ribs (the 4th operation), subcutaneous tissue (the 5th operation), and local recurrence (the 6th operation) was found within 4 years postoperatively. Resection was done for each metastasis, and postoperative radiotherapy (66 Gy) and chemotherapy (CYVADIC) were done. The patient is doing well without apparent recurrence 57 months after last surgery, and survives 113 months after initial surgery. Multidisciplinary treatment may provide longer survival for patients with MFH of the chest wall.     

Survival after surgical resection for high-grade chest wall sarcomas

Indications for chest wall resection of metastatic or locally recurrent sarcoma and for subsequent bony reconstruction are controversial. Twenty-eight patients had chest wall resection for high-grade primary, metastatic, or recurrent sarcoma. In all patients, resection with selective reconstruction of the bony thorax was performed without operative mortality. Since 1980, only patients with four or more ribs resected have had selective bony reconstruction. Follow-up ranged from 8 to 132 months (median follow-up, 42 months). All deaths were related to sarcoma recurrence. The overall actuarial survival rate was 85% at 1 year, 65% at 3 years, and 59% at more than 5 years. The overall actuarial proportion without disease recurrence was 64% at 1 year, 52% at 3 years, and 40% at more than 5 years. There was no significant difference in overall or disease-free survival for patients with primary, metastatic, or recurrent tumors. The most important prognostic factors were positive margins and concomitant pulmonary resection for synchronous lung metastases. These data support aggressive resection to obtain pathologically tumor-free margins for chest wall sarcomas, whether primary, metastatic or recurrent. Reconstruction can be individualized based on the extent of resection.     

Problems in resection of chest wall sarcomas.

To illustrate the problems of reconstruction in major chest wall resection, five patients with a variety of soft tissue tumors of the chest wall, located at different sites, are presented. Patients, who underwent a lateral or posterolateral chest wall resection required removal of two to five ribs sequentially as well as the adjacent soft tissue. Those who underwent an anterior chest wall resection required resection of the manubrium or the body of sternum as well as of adjacent costal cartilages. To prevent instability of the chest, herniation, and to minimize flailing, the chest defect was bridged with the use of Marlex mesh. Whenever possible, the omentum was brought into the chest cavity to increase the vascularity of the reconstruction. Since, in most instances, the tumors involved the skin because of previous damage from radiation therapy, extensive skin coverage was planned well in advance of resection. Pedicle skin flaps or rotation flaps were used to cover the skin defect. Ventilatory support by volume respirator, was required for three to four days. In all patients, the chest wall was completeley stable after three to six weeks.     

Repair of chest wall defects after full thickness surgical resection

The authors discuss the development of their approach to the repair of full-thickness chest wall resection based on a series of twenty-two patients operated between 1967 and 1989. The defect resulting from resection of all tissue planes, either for breast in situ, recurrences, radiation lesions or primary tumours, raises difficult problems. Mammary or cutaneous autoplasties, performed during the early years, have become less frequent, essentially because of the development of musculo-cutaneous flaps (pectoralis major, rectus abdominis, latissimus dorsi) which provide global anatomical and functional repair. The greater omentum island flap, used since 1974, still occupies an important place because of its plastic and trophic qualities in irradiated regions. When chest wall rigidity is compromised, Mersilene patch remains the material of choice. The quality of the results obtained in terms of comfort justifies the use of this major surgery which is now well defined.     

复杂胸部肿瘤切除胸壁重建术患者的康复护理

目的总结复杂胸部肿瘤切除胸壁重建患者的围手术期营养与康复护理经验。方法对10例复杂胸部肿瘤胸壁重建患者,实施饮食指导、康复锻炼、皮瓣观察、疼痛管理等围术期护理。结果 10例患者均顺利康复出院,术后出现胸腔积液3例,皮瓣危象、上肢淋巴水肿、自发性气胸、胸壁软化、心律失常各1例,经及时处理后均好转,伤口I期愈合。术后平均住院时间14.6d。结论胸壁重建是胸壁肿瘤尤其是复杂胸壁缺损的重要手术方法,围术期康复护理能促进患者术后恢复进程,改善预后。     

Long-term survival after resection of pulmonary metastases from carcinoma of the breast.

Resection of isolated pulmonary metastases may yield improved survival in select patients. Between 1981 and 1991, 44 women (median age, 55 years) with a history of breast cancer underwent 47 thoracotomies with no operative deaths and only three minor postoperative complications (3/47, 6.4%). Confirmation of the metastatic origin of the lung lesion was made by direct histological comparison with the primary. Three patients had benign nodules and were excluded, and 4 patients had less than complete resection at thoracotomy. The median survival after thoracotomy of the remaining 37 patients with completely resected metastases was 47 +/- 5.5 months, and their actuarial 5-year survival was 49.5%. Patients with a disease-free interval of longer than 12 months had a longer survival (median survival, 82 +/- 6 months; 5-year survival, 57%) than patients with a disease-free interval of 12 months or less (median survival, 15 +/- 3.6 months; 5-year survival, 0%) (p = 0.004). Patients with estrogen receptor-positive status (n = 14) tended to have longer survival after resection than patients with estrogen receptor-negative status (n = 15) (median survival, 81 +/- 9 months versus 23 +/- 6 months, respectively; p = 0.098). Other clinical variables analyzed did not predict survival after thoracotomy. We conclude that resection of pulmonary metastases in patients with breast cancer can be done safely and may result in long-term survival for a substantial number of patients. Patients with a disease-free interval of longer than 12 months have an excellent prognosis after complete resection.     

Reconstruction of the chest wall following extended interscapulothoracic amputation and chest wall resection

Summary Extended interscapulothoracic amputation is a major operative procedure indicated in the treatment of malignant primary bony and soft tissue tumors involving the shoulder girdle and chest wall. The technique of chest wall resection and its reconstruction is described in two patients with recurrent malignant fibrous histiocytoma following extended interscapulothoracic amputation some months earlier. The stability of the chest wall was restored by using marlex mesh as a sandwich of two layers of mesh with methylmethacrylate interposed. Because of damage of the tissue around the chest wall resection by previous radiation therapy, free myocutaneous flaps were used for closure of the defects. Using this technique for reconstruction of large areas of the chest wall, it is feasible to restore sufficient pulmonary function and to obtain closure under unfavorable conditions. This operative technique can be used as a curative or palliative treatment following interscapulothoracic amputation of recurrent musculoskeletal tumors.     

Completely wide resection of malignant fibrous histiocytoma of the chest wall; expect for long survival.

Malignant fibrous histiocytoma (MFH) rarely occurs in the chest wall. A case of MFH originating from the chest wall is herein reported. We performed radical en-block resection of the whole chest wall together with the tumor and reconstructed it with Marlex mesh. There was no recurrence 4 years after operation. We consider radical en-block resection for MFH and reconstruction with Marlex mesh a safe operation and may provide a long-term survival.     

A new method of stabilizing the chest wall following major chest wall resection

Summary Prosthetic materials, such as metals, marlex mesh and methyl methacrylate have been used for stabilization of the chest wall after resection of large areas of rib cage. Such materials are contraindicated in an infected area. A new method of providing a stable chest wall using autogenous tissue is presented.